ORIGINAL ARTICLE

ANZJSurg.com

Randomized controlled trial of probiotics after colonoscopy

Basil D’Souza,* Timothy Slack,* Shing W. Wong,*† Francis Lam,* Mark Muhlmann,*
Jakob Koestenbauer,† Jonathan Dark‡ and Graham Newstead*
*Department of Surgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
†Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
‡Faculty of Business and Economics, The University of Melbourne, Melbourne, Victoria, Australia

Key words Abstract

bowel preparation, colonoscopy, probiotic.
Correspondence
Mr Basil D’Souza, Department of Surgery, Prince of
Wales Private Hospital, Suite 17, Level 7, Barker
Street, Randwick, NSW 2031, Australia.
Email: basil_dsouza@yahoo.com.au
B. D’Souza MBBS, BSc, FRACS; T. Slack MBBS,
FRACS; S. W. Wong FRACS, MS; F. Lam MBBS, PhD,
FRACS; M. Muhlmann MBBS, FRACS; J.
Koestenbauer; J. Dark PhD Econ; G. Newstead
FRACS, FRCS.
This paper was presented at: (i) Annual Scientific
Meeting of the Royal Australasian College of Surgeons
in Singapore 2014, in the Killingback Prize Section; and
(ii) Tripartite Conference in Birmingham UK 2014, in the
British Journal of Surgery (BJS) Prize Section and is a
winner of the BJS Prize for the conference.
Accepted for publication 22 May 2015.
doi: 10.1111/ans.13225
Background: Up to 20% of patients have ongoing abdominal symptoms at day 2 and
beyond following colonoscopy. It was hypothesized that some of these symptoms are
related to alterations in gut microbiota secondary to bowel preparation and would
improve with probiotics compared with placebo.
Methods: Patients were given either a probiotic or placebo capsule in the days
following colonoscopy. Colonoscopy was performed with air insufflation. The probiotic
capsule contained the strains Lactobacillus acidophilus NCFM and Bifidobacterium
lactis Bi-07. Patients recorded their symptoms at 1 h, 1, 2, 4, 7 and 14 days post
colonoscopy and returned results once their symptoms had resolved. The primary
outcomes used were the length of days to resolution of bloating, abdominal pain and
altered bowel function post colonoscopy.
Results: A total of 320 patients were randomized. After loss to follow-up and with-
drawal, 133 patients were analysed in the probiotic group and 126 in the placebo
group. Patients having probiotic had a lower number of pain days following
colonoscopy, 1.99 versus 2.78 days (P < 0.033). There was no significant difference in
bloating or return to normal bowel habit days (P = 0.139 and 0.265 respectively).
Subgroup analysis revealed that patients with pre-existing abdominal pain benefited
from probiotics in number of pain days, 2.16 versus 4.08 (P = 0.0498).
Conclusion: Our study has shown a significant reduction in the duration of pain days
post colonoscopy in patients taking probiotic compared with placebo. No significant
effect was seen in terms of return to normal bowel function or bloating post
colonoscopy.

Introduction clinical scenarios including irritable bowel syndrome (IBS),5

antibiotic-associated diarrhoea,6 infectious diarrhoea7 and even
Colonoscopy is one of the most common medical procedures per-
pouchitis.8,9
formed. An estimated 14 million colonoscopies are performed in the
This study investigated the three major end points of length of
United States per year.1 Despite this fact, there is little data in the
time of bloating, abdominal pain and altered bowel function in all
literature regarding abdominal symptoms in the days following
patients taking probiotic or placebo post colonoscopy following
colonoscopy. Ko et al.2 showed that up to 20% of patients lose 2
mechanical bowel preparation. Secondary outcome measures were
or more days of normal activity from minor symptoms after
to look at the effect of probiotics on the severity of pain post
colonoscopy. Gut microbiota has been shown to be significantly
procedure and subgroup analysis to see if any features were associ-
altered with mechanical bowel preparation.3 Alterations in bowel
ated with improved outcomes with probiotics.
microbiota have been implicated in contributing to symptoms in
patients with a variety of pathologies4 and may play a role in the
symptoms seen post colonoscopy.
Methods
Probiotics offer a potential therapeutic option to altered gut This study was approved by Belberry Human Research Ethics
microbiota. More recently, there has been an increasing evidence for Committee and by the Medical Advisory Board of the Prince of
the therapeutic benefits of a range of probiotics in a variety of Wales Private Hospital. Informed consent was obtained from all

© 2015 Royal Australasian College of Surgeons ANZ J Surg •• (2015) ••–••

2 D’Souza et al.
patients prior to colonoscopy. Consecutive patients presenting for
colonoscopy or gastroscopy and colonoscopy were enrolled in the
study. All patients had undergone full bowel preparation with three
sachets of sodium picosulfate the day prior. Eligible patients under-
went colonoscopy and those that were not excluded were then
randomized via envelope method to receive probiotic or placebo.
Both investigators and participants were blinded to the contents
of the bottles which were identical in appearance. Exclusion criteria
for study participation prior to colonoscopy were age less than
18, participants already taking probiotics, non-English speaking
patients, an immune-compromised patient or patients with an
American Society of Anesthesiologists (ASA) score of 3 and above.
Patients were excluded after colonoscopy if they had any additional
procedure carried out at the time of colonoscopy such as banding of
haemorrhoids or sphincterotomy for anal fissure, the finding of any
significant pathology at the colonoscopy, for example cancer,
obstruction or colitis, any complication from the actual colonoscopy
such as perforation, aspiration, heart issues or bleeding. All the
procedures were performed using air insufflation. Five experienced
endoscopists accredited for gastroscopy and colonoscopy by the
Conjoint Committee for Recognition of Training in Gastrointestinal
Endoscopy performed the procedures.
Study design
At the conclusion of their colonoscopy, participants were given an
envelope containing the trial protocol and questionnaire and an
unlabelled bottle of 14 capsules containing either placebo or
probiotic. They were instructed to take one capsule on the night of
the colonoscopy and then one every subsequent night until they
considered their bowel function, bloating and abdominal discomfort
to have returned to normal or for a total of 14 days. Participants were
then asked to return the questionnaire by mail in a reply-paid enve-
lope. All participants were called after 3 weeks to aid in data col-
lection and assess compliance. Participants were considered lost to
follow-up if they were not contactable 4 weeks after their procedure.
The questionnaire assessed post-procedural pain using a 10-point
visual analogue score. Demographics, periprocedural information
and pre-existing symptoms were collected in a prospective database.
The probiotic
The probiotic capsule contained Lactobacillus acidophilus NCFM
and Bifidobacterium lactis Bi-07 in doses of 1.25 × 1010 each, yielding
a total content of all strains of 2.5 × 1010 colony forming units (CFUs)
per capsule (Inner Health, Health World Limited, Queensland, Aus-
tralia). The placebo capsules contained the excipient microcrystalline
cellulose which was also present in the probiotic capsule.
Statistical analysis
This trial was designed to have a 90% power to detect a 15%
increase in the number of participants having complete resolution of
bowel symptoms and bowel function at day 3 at a 5% level of
significance. A recruitment target of 260 participants (130 in each
arm) was determined by statistical calculation. A recruitment of 310
participants was targeted to allow for a 20% loss to follow-up and
drop out. Patients were analysed on an intention-to-treat basis.
Statistics were performed by an independent statistician who was
blinded to the randomization. Tests for the differences in end points
and controls between probiotic and placebo used a t-test with
unequal variance for the continuous variables. Fisher’s exact test
was used to test for significant differences in the percentages
between groups. Multivariate regression analysis was performed
using Eviews version 6.0 (IHS Global Inc., Irvine, CA, USA).
It is important to note that patients with increased bloating, pain or
abnormal bowel function after 14 days were recorded as >14 days.
For the probiotic group, there was one patient with pain and abnor-
mal bowel function greater than 14 days. For the placebo group,
there were five patients (two with bloating, one with pain and two
with abnormal bowel function). Descriptive statistics treated these
observations as being equal to 14 days.
Multiple regression analysis used a Tobit procedure to account for
the censoring of the end points.
Results
A total of 353 consecutive participants were assessed for eligibility.
Thirty of these underwent colonoscopy but were excluded from the
trial (10 significant pathology, eight with ASA 3 and above, 10
additional procedures performed, two peri-procedural complications
– aspiration and arrhythmia). Three patients refused to participate.
Randomization was then performed on the remaining 320 partici-
pants. The probiotic group had 159 participants and 161 were in the
placebo group. Caecal intubation was achieved for all the patients
included in the study. There were 20 lost to follow-up and six
withdrawals from the probiotic group and 24 lost to follow-up and
11 withdrawals from the placebo group. Therefore, a total of 259
participants were analysed (133 in the probiotic group and 126 in the
placebo group). Sixty-three patients underwent both gastroscopy
and colonoscopy (32 probiotic group and 31 placebo group; Fig. 1).
Fig. 1. Consort diagram of patient recruitment through to analysis.
© 2015 Royal Australasian College of Surgeons
Probiotics after colonoscopy 3

Table 1 Descriptive statistics

Variable Statistic Probiotic (n = 133) Placebo (n = 126) P value

Controls
Age Mean 61.621 60.127 0.367
Standard deviation 13.746 12.811
Body mass index Mean 26.854 26.916 0.915
Standard deviation 4.771 4.544
Midazolam (mg) Mean 2.187 2.317 0.210
Standard deviation 0.824 0.838
Fentanyl (mcg) Mean 50.644 46.270 0.122
Standard deviation 22.356 22.873
Propofol (mg) Mean 156.136 155.040 0.916
Standard deviation 91.365 75.492
Procedure time (min) Mean 19.242 19.575 0.736
Standard deviation 8.191 7.663
Time since last dose of bowel preparation (h) Mean 10.020 9.883 0.410
Standard deviation 1.357 1.299
Female (%) 44.7 54.0 0.135
Previous surgery (%) 30.3 21.4 0.119
Buscopan given (%) 6.1 4.8 0.786
Procedure (gastroscopy and colonoscopy) (%) 24.2 24.6 0.946
Biopsy/polyp taken (%) 55.3 52.4 0.638
Prior bloating (%) 16.7 19.8 0.523
Prior abdominal pain (%) 19.7 19.8 1.000

Table 2 Primary endpoint data (in days post procedure)

Variable Statistic Probiotic (n = 133) Placebo (n = 126) P value

Bloating Mean 2.000 2.517 0.111

Standard deviation 1.996 3.054
Pain Mean 1.993 2.779 0.032
Standard deviation 2.398 3.361
Return of normal bowel habit Mean 3.054 3.422 0.280
Standard deviation 2.198 3.156

The two groups were evenly matched with regard to demograph-

ics and clinical characteristics (Table 1). There were no significant
differences in operative procedures, procedural time, biopsies/
polypectomy performed, previous major surgery, time from bowel
preparation and intraoperative medication.
There was no significant differences between the proportion of
cases performed in either the probiotic or placebo group by each
endoscopist (P = 0.741).
One hundred and fifty-seven patients (81 placebo and 76 probiotic
group) reported some abdominal discomfort and 119 patients
(59 placebo and 61 probiotic group) reported bloating above pre-
colonoscopy levels in the first 1 h following colonoscopy.
Patients having the probiotic had a lower average number of pain
days from 2.78 to 1.99 days post colonoscopy (P = 0.032; Table 2).
This was confirmed on multivariate regression analysis (P = 0.044)
and on Kaplan–Meier survival curve analysis (P = 0.027; Fig. 2).
There was no significant benefit of probiotics on length of time
of bloating symptoms at 2 versus 2.52 days (P = 0.11). There
was also no significant difference in the time to return of normal
bowel function between the two groups at 3.05 versus 3.42 days
(P = 0.288).
Patients having probiotic capsules did not report a significant
Fig. 2. Kaplan–Meier survival curve for differences in pain resolution
difference in the severity of pain using the visual analogue scores at between probiotic and placebo (P = 0.028).
1 h, 1, 2, 4, 7 and 14 days post colonoscopy compared with placebo.

© 2015 Royal Australasian College of Surgeons

4 D’Souza et al.
Various subgroup analysis were then performed, the results of
which are mentioned here. The tables (Tables S1–S5) can be found
in the supporting section.
It was found that patients with pre-existing abdominal pain benefit
from probiotics. Table S3 reveals that the average number of pain
days is lower for the probiotic than the placebo group (2.160 versus
4.084 days, P = 0.072). Multivariate regression analysis indicates
that this was significant at the 5% level (P = 0.0498).
Discussion
This is the first study to investigate the effectiveness of probiotics in
relieving post-colonoscopy symptoms. It is a pilot study intended on
reflecting real-world practice in that all-comers (without significant
pathology, complication or additional procedure) to a colonoscopy
day procedure unit were eligible for inclusion. Our study showed a
significant reduction in the length of time taken for resolution of
abdominal pain following colonoscopy in patients taking the
probiotic tablet compared with placebo. There was no significant
reduction in time to resolution of bloating or return of normal bowel
function.
There is a relative paucity of data looking at minor complications
post colonoscopy. This is usually because of the perceived lack of
clinical relevance of these symptoms given that they are usually mild
and self-limiting. Despite this belief, previous studies have indicated
the rate of minor complications to range from 15 to 30% of patients
undergoing colonoscopy.10,11 Bini et al. showed that there is a sig-
nificant association between negative outcomes and decreased sat-
isfaction in patients undergoing colonoscopy. Furthermore, patients
who reported negative outcomes were significantly less likely
to agree to have an endoscopic procedure in the future if it was
deemed necessary. This in turn may result in non-compliance, poor
follow-up and wasted resources.10
Having mechanical bowel preparation has been shown to alter gut
microbiota.3 In this regard, similarities are drawn to IBS. In fact,
early culture-based studies of faecal matter in patients with IBS
also showed decreased lactobacilli and bifidobacterium.12 Multiple
randomized controlled trials have shown a clinical benefit of
probiotic intake in patients with IBS.7
The proposed mechanism of action of probiotics include inhibi-
tion of pathogen binding,13 altered immune function,14 improved
colonic transit and motility15 and alterations in visceral hypersensi-
tivity.16 A study by Rousseaux et al. also demonstrated that
L. acidophilus increased the expression of l-opiod and cannabinoid
receptors in normal animals.16 The majority of studies used
L. acidophilus or bifidobacterium although with varying strains. It is
difficult, however, to make generic comments about these probiotics
because of the heterogeneity of the studies, the quantity and varia-
tion in strains used and measured outcomes. We had selected the
probiotic capsule used in our trial because it is readily available in
Australia, not overly expensive and the genus and species used have
been extensively investigated in the past. The clinical benefits of
probiotics are known to be strain-dependent. The fact that we have
used a combination probiotic, however, makes it impossible to know
whether the results are due to one of the strains used or a symbiotic
effect.
Both groups in our study were very evenly matched with factors
such as body mass index, sex, length of time of procedure and
number of polypectomies/biopsies, etc., which have been shown in
previous studies to be significant indicators of post-colonoscopy
pain.17 We also asked patients about pre-existing abdominal pain and
bloating with the view that this may affect their post colonoscopy
symptoms. Both groups were evenly matched for patients with either
or both of these symptoms. Subgroup analysis of these groups of
patients revealed that patients with pre-existing abdominal pain were
more likely to benefit from taking the probiotic than those with
bloating or bloating and pain combined. However, the numbers in
these groups were small and the results need to be interpreted in this
context.
A total of 63 patients also underwent gastroscopy in conjunction
with colonoscopy. Previous studies have reported an increase
in post-procedural pain in this group of patients, possibly related
to increased procedure time and increased gas insufflation.10,11
However, in our study, a similar proportion patients in this subgroup
reported pain and bloating compared with the colonoscopy alone
group (P = 0.374 and 0.673) at 1 h. This subgroup of patients also
did not show a significant benefit from probiotics in terms of reso-
lution of pain, bloating or return normal bowel function. This may be
due to the smaller number of patients analysed here.
Carbon dioxide (CO2) insufflation for colonoscopy has been
shown in a recent meta-analysis to result in reduced abdominal pain
post colonoscopy compared with air insufflation at 1, 6 and 24 h.
The maximal effect was at 1 h where the CO2 group was associated
with a relative risk of post-procedural pain of 0.26.18 The mechanism
of reduced pain is thought to be a combination of rapid absorption
from the intestines (160 times more rapidly than nitrogen and 13
times more rapidly than oxygen the two main components of air) and
improved visceral blood flow through vasodilatation.19 In our study,
we did not have access to CO2 insufflation and hence used air
insufflation. This is in keeping with the majority of endoscopy
centres in Australia at present although this is gradually changing
over time. With CO2, the maximal benefit for pain/bloating com-
pared with air is seen early post procedure but there is still
a subgroup of patients (5–32%) that have ongoing symptoms of
pain at 24 h post colonoscopy.20 It remains to be seen whether
these patients would benefit from the addition of probiotics
peri-procedurally.
Conclusion
In conclusion, our study has shown that a single capsule of probiotic
containing 2.5 × 1010 CFUs of L. acidophilus NCFM and B. lactis
Bi-07 taken daily starting on the night after colonoscopy resulted in
an earlier resolution of abdominal pain from 2.78 to 1.99 days. We
conclude that this reduction in time of post colonoscopy pain is
significant in that most patients go back to work the day after their
colonoscopy, this is despite the pain being only mild, based on visual
analogue scores. The compliance with treatment was high in those
who were not lost to follow-up with 98% in each group taking the
probiotic according to instructions (three non-compliant in each
group), suggesting that this is a simple intervention that would be
readily taken up by patients.
© 2015 Royal Australasian College of Surgeons
Probiotics after colonoscopy
Newer studies using CO2 insufflation should also aim to measure
actual changes in pre- and post probiotic faecal microbiota and
correlate that with patient’s symptoms in order to provide some
objective measurements to symptom relief. More molecular research
is required into the mechanism of action of probiotics leading to
more refined hypothesis-driven and patient-focused clinical trials in
the future.
Acknowledgement
The lead author would like to thank Dr Peter De Cruz, Gastroenter-
ologist, Austin Hospital Melbourne, for his insight and guidance.
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Supporting information
Additional Supporting Information may be found in the online
version of this article at the publisher’s web-site:
Table S1 Comparison of colonoscopy to colonoscopy and
gastroscopy.
Table S2 Comparison of probiotic and placebo for colonoscopy and
gastroscopy subgroup.
Table S3 Comparison of probiotic and placebo for pain subgroup.
Table S4 Comparison of probiotic and placebo for bloating sub-
group.
Table S5 Comparison of probiotic and placebo for bloating and
pain subgroup.
Table S6 Comparison of pain by operation type.
Table S7 Comparison of bloating by operation type.